WTA 2024 podcast

All right, welcome back to Behind the Knife and thanks for listening. This is Patrick Georgeoff, trauma surgeon at Duke University, and today we are recording from beautiful Snowmass, Colorado, home to the Western Trauma Association's 2024 meeting, aka the Fellowship of the Snow. And today we're going to discuss a few hot topics that caught the interest of conference attendees.

We're going to talk about resuscitative thoracotomy, pre hospital blood, and irrigation of chest tubes for hemothorax clearance. And I'm happy to be joined today by Ron Tesorero, who is the associate professor of acute care surgery at Zuckerberg San Francisco General Hospital. He's also a director at UCSF's acute care surgery fellowship and co director of the SICU there.

Welcome, Ron. Thank you. I have Thomas Carver, who is Associate Professor of Acute Care Surgery at the Medical College of Wisconsin. He's also their ACS Fellowship Director and Senior Medical Director of Critical Care Services. Thomas, thank you. Thanks for having me, Patrick. And we have Juan Duchesne, who is Professor of Surgery and Chief of Trauma and Acute

Care Surgery at Tulane University.

Welcome. So we're going to start with Ron today and you gave an update on Resuscitative Thoracotomy. So this is a newly updated algorithm. And before we dive into that I want to make note of the fact that we had episodes 475 and 476, which were in March of 2022. We discussed in detail the who and the how of Resuscitative Thoracotomy.

So that might be worth going back and listen to. And I should note that we are now over one, 725 episodes. And the easiest way to find these episodes that are buried back in time is to go to our website or use the new app, which is available on Apple and Android. You can search by topic, or you can even browse by podcast series.

So it's easier. To navigate. So, Ron, the la the last WTA guideline was in 2012, is that right? That's correct. Right. And then since then, east also put out a guidelines, is that right? Yeah, east put out their practice managing guideline in 2015 on patient selection for Ed thoracotomy. And then, you know,

there have been a number of series meta-analyses and.

Registry trials since then that have sort of informed our decision making. And a bunch of research that's gone into trying to really figure out which patients would most benefit from resuscitative thoracotomy. Alright, so WEST was last updated in 2012, EAST in 2015, right? And one of the keys to the Western Trauma Association guidelines was related to time, is that right?

That's correct. So the Western Trauma Association guideline in 2012 Looked at, did look at signs of life, but for patients who had absent signs of life, looked at And a lot of that was really based off of the seminal work from a paper in 2011, which began from the Western Trauma Association, which was looking at the limits of recessive thoracotomy.

And so they looked at patients with both penetrating and blunt trauma, all comers that got a recessive thoracotomy and see you saw who they had survivors in. And so there were no survivors in the penetrating trauma group. beyond 15 minutes of CPR and the blunt trauma group beyond 10 minutes of CPR. I do think it's important to

note, and this is in the algorithm, is that when you get to the limits of those times, especially in blunt trauma, the only survivors they had had tamponade.

So I think it's important even, you know, in the current algorithm, I'm sure we'll get to that. We still have these times in there. I think it's important to note that when you're looking at blunt trauma at the extremes of those times, that the only survivors in that prior group were patients that had tamponade.

Right. And ultrasound was not mentioned in the 2012. Right. The guideline, which is a huge, you know, addition here. And contrast that with the EAST guidelines in 2015, which did not include time, is that right? That's correct. The EAST guidelines in 2015 did not include time. I think they specifically removed time from their algorithm on purpose because there's not a lot of data for it.

But I think that many people found, although the guideline is fantastic and I think it's very evidence based using GRADE, I think in real time with patient care, a lot of people had difficulty figuring out who they were going to apply thoracotomy to based off those practice management guidelines.

And let's start with a patient who comes in very sick, a pulseless CPR is in progress and they

have the no signs of life, which again, what are those? So the most commonly utilized signs of life were originally described by the American College of Surgeons Committee of Trauma Practice Management Guideline in 2001.

And they're the same signs that were used in the prior WTA algorithm and in the East Practice Management Guideline. And those are pupillary response, any evidence of spontaneous ventilation, extremity movement. Palpable pulse or measurable blood pressure or pulses or, excuse me, electrical activity.

Right. Okay, so we have a patient who has none of those signs of life. What do we do next? If you have none of those signs of life, then based off our algorithm, which is strongly informed by the prior algorithm, we look at what's the mechanism of injury. And what's the duration of CPR? And so for, again, for patients who have penetrating trauma, who have CPR of less than 15 minutes, then we'll consider recessive thoracotomy.

And for blunt trauma, who have CPR of less than 10 minutes, we'll consider recessive thoracotomy. Right. So, so similar to the prior guidelines, but now there's something new after that, right? We bring in ultrasound to look at cardiac motion. Yeah. So we

bring an ultrasound to look at cardiac motion because there are several research papers that have shown that if you don't have cardiac motion on ultrasound, there's no survivors of recessive thoracotomy and no organ donors from recessive thoracotomy.

So I think many places have already included this in their algorithms to look at ultrasound to see, is there any cardiac activity in that? Right. And in addition to cardiac activity, you're also looking for tamponade, correct? That's correct. And so in the absence of cardiac activity, in the absence of tamponade, then that person is declared dead, correct?

That person is declared dead. Now there's a couple of caveats there. You may not be able to get windows, right? And then, there's some, this is not really in the literature, I'll ask the rest of the group if they've seen this, but there were a few people on our panel that said that tamponade sometimes is difficult to diagnose in asystole.

So that's in the algorithm to say, if you're not sure, and the patients meet criteria, then it's really a surgeon discretion as to whether to move on. But if you don't have tamponade and you don't have cardiac activity, then you should terminate resuscitation. Those patients are dead. Yeah. I think there's a couple of things and I've looked at this.

I'm a big ultrasound guy. I, in fact, it's one of my like, highlights of my life is how. Much ultrasound I use and how much I teach. Two things that come out. One, I've had people who they have tamponade and it's been misinterpreted as a systole or no cardiac motion and they terminate resuscitative efforts.

In fact, it's very clear. That's tamponade. The other one is what's actually cardiac motion, right? So any cardiac motion and organized cardiac activity are two different things, right? Organized cardiac activity. The people that survive. Resuscitative thoracotomies are pseudo PEA. Right? Their heart is beating, they just need volume.

It's not the person whose heart stopped, right? But twitch of the cardiac muscle versus the valve opens and closes are two different things. And I have found that there is a big disparity. Within my group, or not even within my group, but within trauma surgeons

capabilities of interpreting that ultrasound.

Not only getting the windows, but interpreting it. And that, that I think is a big piece of adding to this algorithm is how do we do? Because my emergency room colleagues and some of my partners disagree. No, I think that's a fantastic point, Tom, and I agree when I just see a twitch of the heart, that to me is not really organized cardiac activity, especially if we've already done some resuscitation measures on the patient, they've gotten a little bit of volume and that's all they have.

I don't think that's a prediction of survival. I do think that the other group that's really difficult is I think many people have conceived as why complex bradycardia is a non survivable rhythm, I don't know what to do with that when there really is an organized contraction of the heart. Yeah. I think that's an area that we don't know.

Yeah. Whether they actually will benefit from recessive thoracotomy, either with a neurologic survivor or potential organ donor. We'll maybe get into the ethics of that later. But, and that's part of this, and part of your algorithm here, if you, you know, we were talking about no signs of life. You have a a line here for signs of life, but

only if it's electrolectivity from on the cardiac monitor.

And if that's the case, you know, you sh, we shunt back over to ultrasound to see. Does that match up with some kind of actual cardiac motion activity? And that's a huge gray area, as you mentioned, and can at some point kind of be in the eye of the beholder and probably does. Then at that point, you probably do want to take into account more, how old is the patient as well?

How long, you know, how clear is this story, you know, from EMS, how, what is the real time, you know, limits to this. And all of that is extraordinarily nuanced and difficult to make those decisions in the trauma Bay and to, teach trainees and the whole trauma team, you know, the nuance of these decision making because there's nothing worse than declaring a patient when they have a heart that's like we're twitching around, you know, after getting a bunch of epinephrine or whatever it may be.

Yeah, that's disturbing for some people. So education is a huge part of it and you know, the rationale for making all these decisions, especially if they are in that gray zone of that cardiac motion, organized

or not, PEA or not, you know, is a huge piece of it. Well, I guess my other question for you Ron is and one of the other things that I've seen as an issue with ultrasound, like people wanting to incorporate ultrasound, when somebody dies in front of me in the trauma bay, there's no ultrasound there.

I don't care what the month, like they just get a thoracotomy, right? I've also seen people take that to the extreme and like they lose signs of life in front of me. And then somebody puts an ultrasound and they don't see the heart move and then they stop. And to me, that's an, a, that's a different patient than an in route.

On scene, right? Death. Those are also two different patients. No, I think that's a completely valid point. Although I would argue, I think it's really hard to have a patient that a minute ago had Oh yeah, no. Signs of life and now has no cardiac motion in the absence of tamponade. Okay, I mean I think that's the issue, right?

That's the problem with the ultrasound. The introspection. Yeah, yeah. Yeah, and that's, it's interesting, maybe I can sort of put that in the manuscript of the algorithm and think that if a patient who loses, you know, who's talking to you now loses a pulse, you don't really need to stop for ultrasound.

Unless it's going to change how you're going to approach the patient's resuscitation. And that's, I don't want to get into, I don't think we want to get into. Yeah, for sure. Yeah. And you do have Roboa here on the algorithm. We're not going to go through that today. What are some of the other key points of discussion that the committee had in terms of kind of points of friction or kind of hot topics?

You also mentioned in the presentation areas that need more research that we've talked about one of, a huge one already, which is that cardiac motion and organized activity. Yeah. So Patrick, there were obviously a lot of things we talked about because I put up all of the knowledge gaps slide, but I think the two will, that I'll mention today, are the utility of closed chest compressions, you know, prior to starting recessive thoracotomy and that patient that comes in and rests, is there actually any benefit?

And then how you approach a patient that looks like they have obvious brain injury. And so, you know, I think we all experience patients will come in undergoing CPR or maybe with one of those mechanical compression Lucas devices as well. And we, most of us will continue CPR that we've all. been in

a a place where CPR is actually impeding our ability to do other things.

It's hard to get access, it's hard to get an airway, hard to get those people out of the way to deal with the recessive thoracotomy. And so if you look at the research for is there actually any utility to close chest compressions and traumatic hemorrhagic shock the answer is probably not. You know most of this is animal studies, but if you look at animal studies and some of these are older There's no augmentate if you have no volume in the tank There's no augmentation of blood pressure either systolic or diastolic blood pressure, and there's a nice paper mid 2010s that actually did animal studies on this.

And so they bled the animals down, and they put them into three different arms. You get CPR, you get CPR and volume resuscitation, you just get volume resuscitation. In all arms, CPR did worse. Volume resuscitation alone did better. And so I think though, we don't know, I mean obviously the overwhelming majority of patients that are going to come in are in hypervolemic hemorrhagic shock, but not all.

So it's reasonable to continue CPR, but it cannot impede your ability of doing other things. So I will routinely hold CPR to get access, hold CPR to get an

airway. And then for patients who have clear indications, they come in with penetrating chest trauma, that are clearly going to benefit from direct thoracic exploration, we just move right to recessive orthotic.

And we don't know yet, right, if open cardiac massage is any better. Correct. We don't, you know, there's a nationwide database study that suggested open cardiac massage may be better than closed chest compressions. I recall it's propensity match, but there's still bias in that study. There are a few papers out of shock trauma that have looked at end title CO2 and closed chest compressions and open cardiac massage that uniformly had better end title CO2 and closed chest compressions.

But again, there's. bias in terms of which group you were. I think they're probably equivalents, but I don't think we know that for sure. Okay. And you mentioned TBI. There's a a bit of an update on this newest algorithm. What's the difference compared to the previous one? Yeah, the previous algorithm still had recessive thoracotomy and for a patient that had you know, traumatic brain injury that came in with signs of life or within these sort of time limits.

I think it's really unclear whether aortic occlusion, you know,

from recessive thoracotomy, that's really what you're getting out of recessive thoracotomy really adds a ton of benefit in those patients beyond just volume resuscitation and closed chest compressions. And this closely mirrors what the pediatric recessive thoracotomy guideline, which is just for those patients we recommend medical resuscitation.

and see if they have a response to that. There's still in the algorithm you may consider a recessive thoracotomy on those patients because maybe there's a benefit to or aortic occlusion. Maybe there's a benefit for increased coronary perfusion that probably falls in the realm of those patients that you may be able to salvage for organ donation.

That's a hugely controversial topic. Sure. And you mentioned the pediatric algorithm which I should mention was last year. A recent WTA algorithm is a separate pediatric Edith Orkotomy Algorithm, which should be I think that's out now. Yeah, it's out. It was I think presented two years ago. It was published in the last calendar year.

It's a collaborative algorithm between the WTA, the Pediatric Trauma Society, and EAST. Very well done, and clearly there's, you know, different varying

literatures, and the algorithm is different than adult algorithm based off the physiology of children. Sure. And then one of the things that came up today or during the conference was about the right chest, right?

We're focused on the left chest, getting access for all the different reasons that we do for a needy thoracotomy. How do we approach the right chest? Yeah, so the algorithm says, you know, place a right chest tube thoracostomy or I should say just a finger thoracostomy on the right side to assess. I think that is reasonable.

We all recognize some patients that have hemorrhage on that side will be missed. It's either clotted or it's posterior and you don't actually get the hemorrhage out. I think the, my personal practice is I usually come across the pleura to get into the right side to assess it. I've definitely seen times where a finger thoracostomy leads you to do that.

That means you're coming across the sternum. You don't have to come across the sternum to get into the right chest across the pleura. I routinely make my incision across the sternum so that if I have to get into the right chest, I don't have to go find the knife again. And then I can always find the knife to extend completely to a clamshell if I need to be there.

The other thing in the algorithm, there's at

least, there's one research article out there that looked at initial clamshell thoracotomy to just a left antralateral thoracotomy and showed that in general. Therapeutic chest maneuvers were much easier, which I think we all recognize through a clamshell.

And there was no increased risk of complications, chest wall complications. And so, you can consider just doing clamshells in all those conditions. Yeah, Juan, what's your practice on? No, I think it's a very good, valid point. And the key thing is to stratify quickly in your brain what kind of patients you're dealing with.

If you have blood versus penetrating. For penetrating trauma, in New Orleans, for example, we have a very high rate of penetrating trauma. And it's really hard to say, oh, it's just the left chest. or it's just the right chest. So for patients that come in, that in the need of the racotomy, we I preferentially do a clamshell.

It give me a beautiful exposure. I can cross clamp and open the pericardium right on and then explore on the right side. But for blunt trauma, which is a different animal and different approach, For those kind of patients I preferentially like to do finger thoracosomies immediately

upon the patient presentation.

And I also include DPA, diagnostic peritoneal aspiration because I like to have the ultrasound ready, but realistically, there's so many people in the room that it would be kind of technically difficult just to get an ultrasound. So that would be my bias in categorized for bone trauma. Tom, so yeah, you know, you mentioned, we, like I stopped CPR when they hit the ambulance band, like stop doing CPR and they have the Lucas, the Lucas has a 100 percent prediction of death, mortality, a hundred percent.

They all die. Anyway, we stopped CPR so that they actually start running instead of taking their time. And then. Probe get your monitor and see if it's asystole and we're doing the ultrasound at the same time. Blunt trauma, they still get fingers in each chest. Penetrating trauma, or you know, if there are signs of life.

I'm you know, I get somebody in at least a finger thoracostomy on the right as we're getting into the left chest because then at least that one simple

thing is out of the way when we open the chest. Mark Des Moines is the same run just like you. He's like, put your hand over the heart, get into the right chest there.

If there's blood there, it doesn't come out through your finger thoracostomy and he like advocates for that. And then you just keep going. So that's how we deal with it. Great points. All right, Thomas, let's move on to you and discuss irrigation for the clearance of hemothorax and trauma patients. And hemothorax is, has an incidence historically in the literature of about, or retained hemothorax, I should say, of about 20%, correct?

Yeah. After initial chest tube placement. And there was also a recent East multi center study which highlighted Some of these ongoing challenges associated with the management of traumatic hemothorax, and they demonstrated a 28. 7 percent rate of retained hemothorax across 17 Centers and we know that At least right now VATS is the gold standard for a patient with retained hemothorax in terms of primary management What other

data is there and when it comes to retained hemothoraces and treatment of them?

Yeah, and you know It's fun to go back and look through all that, that historic stuff. And one of the commenters earlier today is like, don't, don't read the review article, read the bibliography. And when you go back into the seventies, people were talking about 40 French chest tubes, right? And putting in second chest tubes, like third chest tubes.

And you come through the eighties and that's the same exact stuff that was highlighted. So, the bigger chest tubes. know, we've proven thankfully, but that was, I mean, that was into my residency, early two thousands. And then You know, Stephanie Savage, there, there was that, you know, there's the whole question about sticking a Yankower directly into somebody's chest and suctioning that out.

A YATS. And doing the YATS and, you know. I've done it. Yeah, no, for sure. It works. Right, there was a, you know, the original paper that came from that was only like 20 people or something. It was a super small pilot, and that group never even followed it up with

anything. And Stephanie is in Memphis, so she, you know, they do this, and they.

And they clear, like they show, and again, not randomize or anything, but they, they found no difference and they just, and then they've, you know, to, to hunt something else down. They're like, well, but our postponed pneumothorax rate went down when we did this. Yeah, I know. Like that was a poor thesis, right?

That was the conclusion of the paper, essentially. So what about thoracic irrigation though? So when did that first come up? So we, I couldn't find anything for retained hemothorax. The original stuff, and so John Weigelt was at the Medical College of Wisconsin for a long time, and he had trained at Parkland.

And at Parkland, you know, they had a huge penetrating trauma. Group and a lot of thoracal abdominals and what they found is they were having all these empyemas when people were shot through the diaphragm and into the stomach and to decrease their rate of empyemas, they would irrigate through the hole in the diaphragm and they'd flush a couple liters through and so we had had this.

This kind of rash of two

or three empyemas in a row in like 2015 or so and we're sitting around the table and John just goes, you know, we used to just irrigate people through their diaphragm and we're like, well, maybe we should just irrigate them through their chest tube and these weren't even shot people like, you know, they didn't have.

GI contamination. They were just developing new empyemas because of their retained pneumothorax. So, we sat down one day and just sort of hung out and thought about how to do it. And we're like, well, we need a funnel. And we're like, a tummy syringe looks like a funnel. And, I mean, we didn't even try it on animals first.

We just went down to the trauma bay and the next guy with a pneumothorax. and we just irrigated his chest and all this clock came out and it was, you know, it was really cool. Yeah. And there was a single center study prior to your multi center study here through West that demonstrated a lower rate of routine, team of the rocks, right?

With irrigation. That was our pilot study. So we got IRB

exemption to try this in the setting of a pilot study. And we went through and actually, you know, we reported a 5% we reported a 5 percent re intervention rate, but that person, it was only one person. And that actually wasn't a re intervention.

It was basically, they got another chest tube because they had a postponed pneumothorax, but we were We counted it because we hadn't really thought about what our inclusion exclusion criteria were going to be. So you had some success with that. And so how did you set up this multi center? So this multi center study, basically we sat around the multi center stuff, you know, trial group and just like pitch the thing, which is, this is how we do it here.

And. I mean, we got approval in 2018. It went onto the website. I got a couple of people that were interested, but really they were only interested in submitting control patients. And so like thoracic irrigation really was. our institution and then the only other early adopter that I could

ever, you know, find was UNLV.

And it wasn't like they ever called me and said, Hey, we're going to start doing thoracic irrigation. It was more like we are doing thoracic irrigation and here are some of our outcomes. In fact, if you look, they presented at double AST and they had a negative study and my heart sunk because we are just starting to do this multicenter.

But really how I set it out to the group was. I'm sure there are people in your group who are interested in doing thoracic irrigation. You will actually be your own, you know, control population. Some will, some will irrigate, some will not irrigate. That's sort of what I expected to happen across all the sites.

So a little behind the scenes look at how the sausages may get these things done. So, so this was a prospective observational trial that compared irrigation versus non irrigation. It was the decision to irrigate was left up to the discretion of individual sites and staff there. And you had a relatively loose protocol, which you recommended a liter of warm saline, although folks could do

whatever they want at each of these sites.

And the primary outcome was whether or not the patient got a secondary intervention. So, that was what did that include? Yeah, so secondary intervention, we had to do a composite, right? I recognize that while our institution did vats primarily for everybody, there's a lot of places that still put second chest tubes in.

And lytics are becoming, or you know, that you read the literature, lytics are becoming more popular. When you look at the studies, lytics are barely being used for retained hemothorax. But we, added all those. Basically, if you got another chest tube, if you got vats or thoracotomy, if you got lytics, we counted that as a secondary intervention.

Okay. Patrick, can I ask one question for Tom? So for these, for the irrigation, this was at time of chest tube insertion. It wasn't like you got a chest x ray after there's a hemothorax and then they got irrigated. No. Very good point. Yep. Good point. We Basically and it's chest tube placed. Sometimes, you know, you'll see this in other, other places.

Are these are talked to get more people's experience on this, right?

They're like, Oh, we put the chest tube in, then we went to the scanner and we saw all this blood in the scanner. So we brought it back and then we irrigated them. The design of this study was you place the chest tube for hemothorax, you irrigate it at that time.

Right. And chest tube output, an initial insertion was not a tract or not a key. So we did in the irrigated group, cause that those people's. hemothoraxes were evacuated directly into a suction canister. So it was measurable, right? If you and we didn't ask the control population, right? That people just get in a chest tube.

We didn't ask them specifically how much blood came out. And that's It's an unreliable number regardless, like how much came out, how much of it spilled on the bed and then like what timeframe, like you hook them up to the plurivac, but then the trauma is going on. So, you know, is it the first hour or what we didn't track that, but we did have the volume of people that got irrigated because that hemothorax was evacuated initially.

So, so for people that say. We

can't do this because we need to move the patient on to get their CT scan. Yeah. How long does it take to do that? About, well, so I have, we have video recording of this. And depends on how you count that, right? If you're counting like the passing off of sterile stuff, which is problematic sometimes because emergency room nurses aren't always used to do right there.

Like, oh, he did battle kind of thing. And they forget and they just hand you. up some sterile tubing. And that's not sterile anymore, right? It took some time just to get him to do that. But it takes about five minutes, plus or minus, you know, it depends on how quickly the hemothorax evacuates and how quickly, like the pouring and all.

Before we go on to the results. So, so exactly how do you do it? So you put a tube in. Yeah. So put a tube into the chest, don't sew it in or anything. We, you know, we put a tube into the chest. We passed off a sterile suction tubing and a sterile Yankauer onto the field. Tube goes in. Sterile Yankower goes into the chest tube and you suction out as much of the blood as you can.

And I move the tube around a little bit to do that.

Alright, the blood's done coming out. You just point the tube up, we take a Tumi syringe, take the plunger out, put it right in the end of the tube and use it like a funnel. And then some non sterile person just on the side of the bed basically is pouring.

Warm, normal saline. So by gravity. Gravity in and the patient's breathing and as they breathe, that fluid just goes into their chest and we'll do that in 500 cc Aliquot. So we'll put in 500, put the Yancar back in, evacuate that fluid out, do it again. Evacuate that fluid out and then hook them up to the suction clearance is an active process.

Yeah, and chest tube size We see a yank our fits in a 28 for instance. Yeah, it fits just fine And we use we're standardized 28 it fits fine because of the ends flared it doesn't It's not a tight seal, right? The Yancar has the flares on the end. So it's not a tight seal and so it really, it's kind of like a sump on an NG tube, right?

It doesn't suck you along completely into the tube. But it will sometimes stop and you move the

tube around a little bit and then more fluid will come out. And I was just going to ask, given that a lot of, a lot of places have started doing 14 French plural catheters and pigtails for hemothoraces, were any of those in the group?

And were there enough that you could actually evaluate those independently? No, not, you know, there were It's a big sigh. Well, it's a big sigh because this was a big question. I did not expect so much variation in chest tube size within institutions or among institutions. So, you know, I won't name one large trauma center in the western United States, but they had five different chest tube sizes reported, ranging from 36 to 14 French, and there was a lot of that, but we controlled for it in the study, right?

Obviously, but what we found in the groups that irrigated, there were only three patients with a pigtail who got irrigated. I will tell you from personal experience, irrigating through a pigtail is so painful, and it

takes a lot longer, and we, and an important consideration though. Yeah, and especially our stable patients who are, supports it and there's a, you know, more and more use of pigtails.

Yeah, certainly, certainly there and experimentally, so we're, you know, so you had asked, Ron, how long does this take in an experimental bedside model? My residents, even if they've never done a manual irrigation, could do one in about four minutes, right? But in the trauma bay, when we watch it on video, it's, it's around five minutes.

Sometimes it's a little longer, it's not. And if they're facile with it, it might be a little shorter, but it's about five extra minutes. Alright, so five year period, eleven sites. 493 hemithoracies. So that can be so 462 patients 123 or 25 percent of those patients were irrigated. Yeah. And so what'd you find?

So we found a significant decrease in secondary intervention rate and those people who were irrigated and raw percents

went from 13 percent secondary intervention rate in the control group to 8 percent in the irrigated population. Right, so an odds ratio of 0. 56 when irrigation was performed. Alright.

So, is this enough data for Juan to go back to Tulane and start irrigating every chest? I mean, I had hoped that our single center study would have been enough data and it's, it is the, you know, I never believe that timeline that people say, Oh, it takes like 7 to 10 years for, for innovation to, to creep through medicine.

But. When we first started this 2018, there were like one center that basically had adopted this and maybe a couple of surgeons across the country that were like, Hey, I'm irrigating people, but none of my partners are. And over the course of the next several years, I could see and I could watch it happen through Red Cap that there were more irrigations occurring in these other sites as more and more individuals were.

gaining exposure to the technique and maybe seeing some of the benefit. Although, you know, there, there really wasn't anything else published. I'll be honest with you. And I when I, when we started the whole process, there was a lot of resistance, right? But then once people started, Yeah.

To the point that now we're saying if you see a VAT, that's a, that should be a no event. That should have never happened. So you've already. Yes, we've been one year and a half now, but using clear the industry tool in so far. We like it and we love it. And we review, we are reviewing because it's a new tool, right?

So we're doing our closed peer review. And what we identified is that that timeline, like you well said, is crucial. Some people wait until they, patient goes to the ICU and then it's a little bit more difficult, but most of the times we're trying to do in the emergency department, it takes five to 10 minutes.

How long is too long to wait for this hemothorax? to become. I will let Tom answer that question, but I will say the longer you wait, the more content, the harder it will be. I mean, if you look at the data out there regarding vats, you wait for that four day window to that,

do that cat scan. First of all, I'm not a firm believer of that data point of 40 or four days.

I think you need to act within the first 24 hours, get this fixed immediately as soon as you can. I mean, they certainly like we got blood. drain that blood out now. If there's a concern like, Hey, this guy's crumping or whatever. And we gotta do, we gotta get out of here. We gotta go to the scanner. Fine. I think that, you know, if you're clearing that clot out and an hour or two, it's probably okay.

But. We don't know that. And I'm just like, you got it. Act on it. It's right here. This is a sterilized place. You're going to be like, this is it. This is the time. So I just kind of move. I move along and just do that. And I've, it's, it's warms my heart one to like, I hear all these places that are starting to do this.

And yeah, yeah. It's not very often in medicine that you come across something or that you're part of something that you think might actually change practice. And you know, just quickly,

just to mention this, as part of the education, you know, one of the comments that we got that was kind of interesting is, but vats is such a cool procedure.

Yeah, I was just going to ask, I don't matter your fellows. Yeah, yeah, yeah. Senior trainees are like, I'm not getting vats now. Yeah, no, my residence, we used to be the place that they got their chest cases. We would do two vats a week. Easy, maybe more. And now it's like one or two a month. Obviously we shouldn't harm patients.

Right, no, I mean, you know, but people, I'm sure they said the same thing when we started doing non op management of spleens. Last question, Does the size of the hemothorax matter? I mean, what if you get a chest x ray in the bay, you have a little hemo pneumo, you put a tube in, and maybe you have 150 cc's of blood out.

Does that person need to be irrigated? So, I don't think we know the answer to that. I think that the East study that they just put out showed about 23 percent of people with a hemothorax less than 300 cc's developed or

retained hemothorax. But yeah, so they had all that data and then they followed those patients and again about a quarter of them ended up getting or having to retain hemothorax.

And my mind like, you know, we can debate all day long which size. You should put a chest tube into but I'm of the mind right now that like if it's a dribble of blood fine, but if it's like There's some blood coming out of this tube or there was blood that came onto the bed. Like we just irrigate them It's not I we have not had an issue with any infections or things like that.

So so on if a Stable blunt trauma patient comes in and you do your workup. Everything's fine. You do you have a hemothorax on CT scan, for instance are you going to not put in a pigtail to treat that so that you can irrigate? Yeah, it's a very good question. We there's a good practice in our system of using pigtails for pneumos, not for hemos.

For hemotorax, we are basically in the range of 28, 24 French size. And, and then we do irrigation once the patient comes from the CAT scan. Great.

Yeah. I'm doing some pig studies right now to look at specifically to try to answer or get some, get some science behind pigtail versus 28 French. I will tell you when you're done, you let us know.

Yeah, for sure. I say a stable trauma patient with a hemothorax. We will put. It's individualized to the surgeon, but we'll put in 14 French tubes based off of some of the studies that have been out there. Yeah, yeah. That's why I was curious about it. It's a fascinating area. Yeah, all I can say is we just don't, we don't know, like, okay, whether or not you're a believer in it, fine.

There's some data out there that says Chest tube size doesn't matter, but what I don't know is chest tube size doesn't matter if you irrigate. I don't know the answer to that. And the other question is whether, you know, should we be intervening on these smaller to moderate sized pneumothoraces at all?

At all, right? Clearly why they get an empyeme, at least in my mind, because it's almost always a skin organism, and a secondary contamination from us putting a tube in in the first place. And to make a plug There's a

WTA multi center trial that's going to try and look at that. Another question too is antibiotics, you know, are you going to be giving one dose of antibiotic with your chest tube?

Do you need to give multiple to prevent that empyema, et cetera? So lots to, lots of answers there. So one, let's move on to you as the last topic. You gave a presentation that was titled Every Minute Counts. extending the continuum of care through early pre hospital blood administration. And so I'm particularly excited to talk about this one because there was a lot of really exciting points that were brought up related to your study.

But why don't you share what y'all did at Tulane and the results? Yeah, definitely. First of all, thank you for having us here. The one of the things that we put together right before COVID was to institute some kind of advanced resuscitative care on the field where we will move the penile of resuscitation closer to the patient.

The reason why we did this is that actually we presented in 2020 double AST basically data that we have not changed the mortality in damage control in the hospital. And, and that was very bothersome and we review our data a couple of

times and we analyze it a couple of different ways and the mortality was anyhow in the 40 percent range.

So because of that, we start looking more closely into what the military have done and through their experience, we decided to try to assimilate some of what they've done with the resuscitation on the field. So this process took four years of a lot of time. Dialogue evidence based reviews, talking to legal team, community education so all these things came into play and we were lucky enough that actually the mayor of the city was very involved and she was definitely in support of increasing their registration efforts on the field.

Which before we go into the further details of the study, that's so critically important what you said. I mean, you, the amount of work that goes into this is, it's cannot be understated. And you guys should be applauded for that as well. But if you're sitting here listening to it and you get you, you want to try to move the needle here, right?

You want to try to decrease. People

die from hemorrhagic shock. This is, this is what it takes. It was a perfect storm. I'll be frank, honest with you. The department of health work hand in hand in promoting and, and helping with this process. And one of the major issues that, and the reason why I'm saying it's a perfect storm is because the gun violence in the onlands was skyrocketing and mortality was skyrocketing on the field.

So all these kinds of things were definitely looking terrible, right? So what can we do? to mitigate that increase in mortality because of the increase in gun violence. And this was the perfect storm. Let's provide the EMS with better tools to basically start resuscitation closer to the scene. What were those tools?

The tools were basically two units of Pacaraplu cells two units of two grams of calcium and two of TXA. And the goal was to infuse these in a very Time sensitive manner that will not delay that much the pre hospital care phase. So these were penetrating patients. who were thought to have hemorrhagic shock based on a systolic blood pressure less than 90,

correct?

Correct. And then you had a pre a pre study time period, 2016 Correct. Compared to the intervention phase was 2021 to 2023. Correct. And 143 patients, what happened with those? patients. Yeah. So we divided them and we have very similar demographics in both groups in the ones that received the advanced resuscitative care bundle versus the one that just received control therapy, which basically was crystalloids and just press on the gas.

That was pretty much the only thing that they did back then. And with advanced resuscitative care, basically there was a, what? we call a satellite ambulance or in transit vehicle that carries at all times the units of blood, the plasma, the calcium, the TXA, among many other things, IOs, junctional tourniquets.

So the EMS team at the scene would radio out and say, and then that unit would come with those supplies. Correct. There's an activation. Everybody mobilized to the activation site. Once police clears the scene. Both EMS and the medic

will go directly to the patient. Once it's identified that the patient is in extremes, the medic goes back to his vehicle, gets his pack, and puts it inside the ambulance that's going to take the patient.

Okay. And Peripheral IVs versus IOs, how is everything administered? Yeah, so that, that was part of the discussion in that four year discussion. Basically we, there was the, no IV access was at no event that would not tolerate a single case like that. So it was basically, we educated everybody, you do your first attempt, first attempt, miss IOs.

No rocket science on this. And we were heading for First attempt at a peripheral IV. A peripheral IV. Fails. Fail, IO. IO needs to be ready and warm. ready to go. So, humerus axis is basically the golden route that we like to prefer to use. Okay. And what were your results? Well, interesting. And I keep looking at the data cause it's just, to me, it's, it's mind blowing to see this.

But even if I don't know the numbers, you talk to EMS people, the EMS will tell you

right on that actually these patients are. They've never had a chance in the past. So our results have demonstrated that the patients with signs of life on EMS first contact time have, are basically have been resuscitated to keep that mortality group in the single digit, 7 percent to up to 11%, depending on what group we analyze.

And when you compare that to the current literature that we have without blood resuscitation, those patients were basically arriving with a chance of mortality of 30 to 40%. Right. All right. So they got two units of blood. It was cold. They got two units of calcium, two grams of calcium, two of TXA. And your mortality, you said, was improved with pre hospital blood administration.

And it increased, I think in the abstract you mentioned, 11 percent with each minute of blood administration delay, right? But I think the most fascinating thing about it is this, it was five or six

minutes longer. Correct. And so, you know, I think one of the things, the first kind of point of discussion we should talk about is this, generally of stay in play versus you mentioned hitting the gas and going.

So you added a good five or six minutes. We know each minute for a hemorrhaging patient like this is critical to their survival. So we added time, but improved survival. Correct. How do you square those things and no it's a great question. And that, and that's every time we discuss this kind of interventions, I am always a hundred percent transparent.

It definitely taking three to five more minutes on transport. But what is happening is that it's not that much how fast you get to the hospital, but can you be fast? And resuscitate effectively the patient makes perfect sense. And that's why it is making a big difference. Although I think that there's, I'm going to be frank, honest in our peer reviews, there's definitely room for improvement on how to get the patient to our destination faster.

Yeah. And they got PAC cells, not whole blood, which is obviously a very

you know, hot topic in terms of preferred resuscitation. Do you think it's just a matter of. Any blood product is going to do, it's going to help. Yeah. Well, I'll be frank, honest with you. I'm a big whole blood guy. I love whole blood for many other reasons, but if you want to increase oxygen carrying capacity, whatever you have, you give it to the patient.

So PacRedBlood sells whole blood. We're using PacRedBlood cells because it's not costing us. We're getting it by consignment from the blood donation bank, which is actually perfect. So our utilization rate is a hundred percent complies. But I will say you can use either one. One, why not just use plasma?

That's what you guys were. What you've actually sort of described is basically like combat casualty care, right? It says in the Navy for 10 years active and 10 in the reserves. And this is, so the only difference is that use humoral IO and we use sternal, but they'd get, TXA was the first administered solution to combat casualty.

Yeah. And,

and it's fun just listening to you tell the story, but part of me, it's just like, they don't need red cells. They need plasma. And I know that people have talked about this for a long time, but you guys just instituted. You got like, you made it happen in your city. You could probably just make that switch.

No, yeah, I think it's a beautiful topic of discussion. We decided just to use factorable cells just to keep the oxygen going. But I don't think that in a fast urban setting, we still don't have level one evidence for that. But I believe 100% If you want to mitigate that coagulative trauma, start with plasma.

Start protecting the endothelium and the glycocalyx. It'd be super interesting if you put plasma, or even plasma and blood out there, and told them, two units of plasma, and if you're not there yet, then you can give the two units of blood. Yeah. You know, and one thing that we've been doing is, actually, once they arrive, because they're not using plasma, the first thing that they get is plasma.

Yeah, we match it one on one. So they don't need all the red cells. They've got plenty of red cells right now. Just give them some plasma. They need resuscitative fluid. That's not Crystalline. That is not Crystalline. Alright. And how did you

come up with the Calcium and TXA doses or to choose to put those, you know, you mentioned the military use of TXA.

How did that be in terms of discussions? Yeah. So for the TXA it was very simple Following the TCC education model we had good collaboration and we identified that actually there was huge room for improvement. Our institution was in the 25% range of use of TXA in emergency department for hemorrhage.

So now that we are implemented by EMS, it, we can give you about the EMS are we are up to 80% compliance, so that make a big difference. So we like to use two grams. I'm a firm believer that if you are giving blood to a patient that is in hemorrhage TXA at some point is going to do its job.

So some people will say, You need to get a tag before you do a TXA. I'll get a tag once the patient is more stable, to see where I need to head with this patient. But in the pre hospital arena, just give it to the patient if they're in hemorrhage. For calcium, I'm so sorry, but for calcium I need to I need to say that

we done analysis and my major concern, and this is something that's going to evolve very soon.

There is a chemical component of damage control resuscitation that people are not paying attention. And that is, what is that electrolyte disturbance? How many, and I will, I would love to ask you both all of you, when you have a patient you're doing, you're giving blood, everything is going fine and you're closing out the medication codes and you're like, what happened?

Well, that, if you're doing a lot of MTPs, you will realize, and if you're not following those patients with a close eye stat, looking at those electrolytes, that, that patient can go in, in full code mode, basically you're giving a lot of citrate, in blood, so basically you are going to be, your calcium is going to go low, and your K is going to go high, because of the PRBC, so you are going to put them in cardiac arrest.

So those kind of things, that damage control resuscitation for electrolytes, there's more to come. And I think that this is an empiric administration at this point in time. At least it's empiric because of the 40

percent incidence of hypocalcemia for patients with severe hemorrhage on presentation. So that goes with a death diamond.

So death diamond is something that No trauma center, a mature trauma center should see that should not exist. Yeah. But you know, it's been described so it is now in our hands to make sure that we mitigate that and that should never be seen what remind us of what the death diamond is. So you're gonna have your acidemia, your colo your hypocalcemia and they say hypothermia.

So hypothermia. So, yeah. Okay. This is the addition of the calcium to the classic triad. So, Mm-Hmm. Exactly. Yeah. To the death triad. Correct. The only thing I was, you mentioned, I used to be a tag first type of person, just based off the data that fibrinolysis shutdowns more common than hyperfibrinolysis and worrying about thrombotic complications.

But I think we have enough data now to say that TXA doesn't increase thrombotic complications independent of what they actually present and to just go ahead and give TXA to these patients. It's interesting to see the swing now. So I've been around WTA and WLAST now like 10

12 years and that early phrase was like everybody was TXA, TXA, TXA and about, I don't know, Four or five, six years ago, people were like, TXA and now TXA is kind of back on an upswing.

So I think a lot of people, they saw the papers that looked at vibrant license shutdown and said, well, if you give this to those people, they're all going to get thrombotic complications. Correct. if it's not causing harm and there's a very real potential for at least some benefit and especially in this patient population who have such high mortality rate, I'm sure.

All right, last question then too. So you mentioned, and we actually had a pro con debate on this earlier as IOs as an access in the setting of trauma and high volume resuscitation. Any thoughts on that? And also you know, how product was administered in the field. Yeah, I think that IOs if they come with an IO and that's your only access, you go for it, right?

So you're going to use it. Once the patient arrives to the trauma center we keep using the IO, but we try to get a better access, a bigger access for this kind of patients. And if we don't, if we can't, we just put a second IO. It's very simple. You know, That, that waste

of time of second, third tryout for IV access is just compromising resuscitation.

So if you have IOs in your institution and you have one and you still cannot get a good IV access central just put another second IO is the nature of the beast, expand the volume first. So you'll go IO central access attempt on arrival and not IO, second IO. Yeah, correct. Yeah, correct. Got it. And we're a group of folks are actually working on a study right now.

It's a cadaver based model, but as a step up kind of approach using IO first and and then move approximately for your central line after you've resuscitated some which I mentioned too, and as part of our innovation series earlier our social education fellow, Dan she's, and I interviewed Dr.

Mark Peel, who had created a device that allowed for more rapid. It is a handheld device that allows more rapid infusion of fluids, including. including blood. And that was used in this study via those I. O. S. Because sometimes it's hard. The flows through I. O. S. Can be quite low. It can be very challenging for something like a pressure bag alone.

And so there was a particular device used in these studies that allow rapid transfusion. Correct? Correct. And the main reason why we did this is because when we look at the data that came from combat analysis, right? Those spaces were arriving with the first unit of plasma hanging still. So we said, wait, there's something here that we, that must need to be changed.

And if we're going to give two units of blood, the only way we can do this is with some kind of a rapid infuser. Now, obviously we cannot move a big infuser, so we decided to go with a handheld infuser. Yeah. It's a life, life flow. It's a non powered, non warmed at this point, but an effective tool as well.

And so I, to wrap it up But again, I think this kind of these projects are very inspiring, right? For people who are listening to trauma surgeons or interested in the field any, anything you learned about the process, you know, this long multi year process of instituting this. And obviously there's gonna be a lot of iterations and growth and changes as you go forward.

But as people want to make a major impact on their local populations and through their trauma center, what would you have to say to them? You need to bring them to the

table. I think that that's the key thing. A lot of systems unfortunately treat first responders just like, you know, a glorified Uber. I'm just being honest.

And that mentality needs to change. We need to empower those first responders on what things they can do. Right to resuscitate the patient effectively and bring it at the same time in a fast manner to us So having this direct communication with them, I sit with them pretty much every Friday. We do peer review They, they're one of the first centers that have CAM records for all resuscitations and trauma activations.

That's great. So we review the cam VI videos and we review basically every single trauma transfusion goes to image trend. Image trend. Send me an email and I review it with coordin, a quality coordinator on a daily basis based on how many we use. So it is extremely important that that connection.

in the pre hospital arena exists. It's not just, I'm in the trauma center, they better do this. No, that doesn't work. It needs to be a big coalition. Fantastic. Alright, well, Ron,

Juan, Thomas, thanks for We could go on forever, honestly. This has been a fantastic conversation. I appreciate you guys taking the time out of your time to go skiing.

Super fun. That's right. for having us. Yeah, really cool. Thank you for listening. Remember to dominate the day.